The proposed project tests an intervention to improve outcomes in patients with end- stage renal disease (ESRD). Patients treated with hemodialysis are at disproportionally high risk for hospitalizations which are both costly to the health care system and are associated with high morbidity and mortality. A portion of hospitalizations in patients on hemodialysis are avoidable and may reflect a failure of self-management of dialysis parameters and adherence. Patient education that is provided by dialysis facilities focuses on dialysis quality metrics set by Medicare for reimbursement purposes. They seldom inform patients about concrete skills, nor do they increase self-efficacy with regards to behavioral outcomes. Patient level barriers to dialysis self-management include low knowledge about the relation of fluid metrics, dialysis adherence and dietary plans to short and long-term outcomes. We aim to employ the Information, Motivation and Behavior (IMB) Skills Model of improving adherence in medical care. We will use a peer mentorship model to provide information and motivation in order to improve adherence behaviors in patients with ESRD. Peer mentorship has been shown to increase theoretical and practical knowledge in patients with chronic disease, and peer-mentors increase perception of social support and self-efficacy in their mentees. We propose a pragmatic trial evaluating the effects of a peer-mentor program focused on increasing dialysis self-management in high risk patients on hemodialysis. Our primary outcome is the composite of emergency department visits and hospitalizations. Our study will be conducted in 2 geographic locations (Bronx, NY and Nashville, TN) to evaluate scalability and acceptability in different patient populations. We will recruit 20 peer mentors and train them using a curriculum based on the IMB model of improving adherence. Two hundred patients with ESRD will be recruited from 7 dialysis centers and will be randomized to either the peer mentorship intervention or a usual care control group. Trained mentors will implement a telephone intervention for 3 months and participants will be followed for an additional 15 months to evaluate study outcomes. This proposal is innovative and addresses challenges related to patient level barriers to self-management, high hospitalization rates and disproportionate morbidity and mortality with a low cost, scalable and pragmatic intervention.